Patrick DeHeer DPM FACFAS's bloghttp://www.podiatrytoday.com/blog/289
enMy Top 10 Tips For Being An Excellent Podiatric Residenthttp://www.podiatrytoday.com/blogged/my-top-10-tips-being-excellent-podiatric-resident
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>The month of July brings about the debut of new residents and the ascension of current residents in podiatric residency programs across the country. I have worked with residents in various capacities over my 20-plus years of practice. With that in mind, I would like to offer those newbie residents and those second- or third-year residents my top ten pointers to being an excellent podiatric resident. More importantly, I hope to help you get as much out of your residency program as possible.</p>
<p><strong>10. Be on time.</strong> Your attending should never be at the OR, hospital or clinic before you. Being early gives you time to make sure appropriate equipment is readily available and necessary paperwork is complete. </p>
<p><strong>9. You should make each minute of your day a learning experience. </strong>Do not fall into the trap of a "country club residency." I realize you need time for yourself, your family and friends. Finding balance can be difficult. Just remember your residency often sets the course of your entire career. If you happen to finish a day early, see if you can go to an attending physician's clinic. Spending time in a clinic is an excellent opportunity to get office experience including patient communication, billing and coding, staff management, charting, etc.</p>
<p><strong>8. Attend every conference, journal club, hands-on lab or lecture you possibly can</strong><strong>.</strong> Your job is to learn and these opportunities are "extra credit." These opportunities broaden your educational base by providing additional teachers outside of your program.</p>
<p><strong>7. The first step to being a good surgeon is being a good assistant.</strong> You want to do and not assist. Everyone knows that. Start by becoming an excellent assistant who anticipates everything while prepared for anything.</p>
<p><strong>6. Be prepared for every surgical case every time.</strong> You must read about upcoming cases and be aware of alternative procedures/approaches/techniques/products.</p>
<p><strong>5. Write, research and lecture as often as you can.</strong> There is nothing more significant you can do to further your education than writing or doing research or preparing/giving a lecture. The benefits are immense and they help build your curriculum vitae as well. You are keeping you CV up to date and current, right?</p>
<p><strong>4. You can learn from both good and not so good surgeons. </strong>Learning what not to do can be as important as learning what to do. Critically review every case you do to evaluate what went right and what could have gone better. Use the information as building blocks for each subsequent case.</p>
<p><strong>3. Make sure you are a member of the American Podiatric Medical Association (APMA) and actively follow the Young Physician Section information, and your state association</strong><strong>. </strong>I am of course biased on this one as a member of the APMA Board of Trustees. I believe we are stronger together, especially as a relatively small group. The APMA and state associations are the very best resources available to you. The APMA created the Young Physician Section for you and it exists to help you along your professional journey. Join as many foot and ankle related organizations as you can as several do not charge residents for membership and offer outstanding educational opportunities. Being involved in your profession is not only paying it forward but is also one of the best investments you can make in your future.</p>
<p><strong>2. Ask “Why” often.</strong> A good teacher is always willing to explain the "why." Some may offer it, some may need to be asked and some may be irritated by being asked, but ask respectfully "why?" When you understand the "why," you, in fact, understand.</p>
<p><strong>1. Read and then read some more. </strong>Wear your library (digital or bricks and mortar or both) out. In a previous blog, I listed my top ten podiatric textbooks (<a href="http://www.podiatrytoday.com/blogged/my-top-10-essential-podiatric-textbooks">http://www.podiatrytoday.com/blogged/my-top-10-essential-podiatric-textbooks</a>). Peer-reviewed journals are equal, if not more relevant, to books. Here are my favorite journals: <em>Foot and Ankle International</em>, the <em>Journal of Foot and Ankle Surgery</em>, the <em>Journal of Bone and Joint Surgery, Clinics in Foot &amp; Ankle Surgery, Clinics in Podiatric Medicine and Surgery</em>, the <em>Journal of the American Podiatric Medical Association, Foot &amp; Ankle Specialist, The Foot</em>, the <em>Journal of Foot &amp; Ankle Research, Clinical Biomechanics</em>, the <em>Journal of Biomechanics, Gait &amp; Posture, Diabetes Care</em>, and the <em>American Journal of Sports Medicine.</em></p>
</div></div></div>Thu, 16 Jul 2015 12:45:12 +0000Patrick DeHeer DPM FACFAS5211 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/my-top-10-tips-being-excellent-podiatric-resident#commentsFirearms In The Practice: Have You Addressed This In Your Office Policies?http://www.podiatrytoday.com/blogged/firearms-practice-have-you-addressed-your-office-policies
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>I do not like guns. I never have and never will. I do respect and honor the Constitution including the Second Amendment, even in its bastardized current interpretation. For disclosure purposes, I am a proud member of Moms Demand Action for Gun Sense in America and Everytown for Gun Safety. I am not writing this blog to argue about guns. Therefore, I have asked the editors of <em>Podiatry Today</em> not to allow any comments pro-gun or con-gun, but only allow comments about the point I am about to make. So relax, continue reading and consider the question I will be posing.</p>
<p>There is a significant push by the National Rifle Association (NRA) for open carry in public places like college campuses, grocery stores, malls, parks, public office buildings, etc. The question as it applies to medicine is will you allow open carry in your office and do you have an office policy on this one way or the other?</p>
<p>Privately owned business can decide their policy on this subject. For example, Starbucks initially allowed open carry in its stores but due to public backlash, changed its policy and does not allow open carry in their stores. Conversely, Kroger as of now still allows open carry in its supermarkets. Certainly, local ordinances vary from state to state and this may be a non-issue for your location. </p>
<p>I currently do not have an office policy regarding this matter. I have a practice with multiple offices, most of which are in hospitals. Often times, the hospital will have a policy about guns that may serve as your office policy if you are in agreement with it. If you disagree with it, you will need to produce your own policy. I cannot imagine a hospital not allowing smoking but allowing open gun carry on its campus. </p>
<p>In my opinion, it should not even be a question but the increasing pressure to push the boundaries of the Second Amendment makes it a question that you should answer before you find yourself in at least a very awkward situation and, at worst, a very dangerous one. I do not feel comfortable with guns in my office. Patients who carry firearms will not be allowed to carry them into any of my offices. They are welcome to leave them in their automobiles or homes.</p>
<p>I am betting that most practices out there do not have a policy on this either way in their office policies and procedures. You do have an office manual with policies and procedures, right? Another aspect of this applies to employees. Are you going to allow a physician or medical assistant to bring a firearm into the office? I believe the same policy you have for your patients would apply to the employees but ultimately that becomes your decision for your office. </p>
<p>I hope you can look past my beliefs and your own beliefs about guns to honestly answer this question and then devise policies and procedures for your office. Do it sooner rather than later.</p>
</div></div></div>Wed, 17 Jun 2015 12:39:31 +0000Patrick DeHeer DPM FACFAS5124 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/firearms-practice-have-you-addressed-your-office-policies#commentsWhy It Is Important To Evaluate Shoe Heel To Toe Drop In Patients With Equinushttp://www.podiatrytoday.com/blogged/why-it-important-evaluate-shoe-heel-toe-drop-patients-equinus
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>The role of equinus in lower extremity pathologies is well documented in the literature. In fact, <em>Foot and Ankle Clinics of North America</em> dedicated its entire December 2014 edition to “The Gastrocnemius.”<sup>1</sup> Much of the literature has been directed to the surgical and non-surgical management of equinus, conditions associated with equinus, and the evaluation of equinus. Little attention has focused on the role of shoe gear on equinus with the exception of the anecdotal literature on high heels.</p>
<p>Recently while lecturing in Ohio, my fellow <em>Podiatry Today</em> DPM Blogger, Nicholas Campitelli, DPM, led a profound discussion on the surgical treatment of equinus. He discussed the role of shoe heel to toe drop in our everyday shoe gear and equinus. Certainly, women’s shoe gear has a higher heel to toe relationship than most men’s shoe gear but even most men’s dress shoes have a significant heel to toe drop. Additionally, the vast majority of running shoes still have heel to toe drops of 12 to 16 mm.</p>
<p>The foot and ankle community’s attention to treating equinus is commonplace, but what about the 12-plus hours a day the patient is wearing a 12 to 16 mm heel to toe drop? This elevation of the heel relative to the forefoot must negatively influence the treatment of equinus. Is time to include patient education about heel to toe drop in shoe gear in the comprehensive management of equinus?</p>
<p>I believe it is an important conversation to have with our patients. For example, when treating a patient with plantar fasciitis non-surgically with gastroc soleus stretching, part of that treatment should include shoe evaluation and education. Consider an 8 mm heel to toe drop shoe a compromise zone for heel to toe shoe drop. This is a good starting point for most equinus patients with an eventual transition to a 4 mm or 0 mm heel to toe drop.</p>
<p>The role of shoe gear in the treatment of equinus is something that we have not appreciated and have undertreated. One must evaluate shoe heel to toe drop in patients with equinus and include it as part of the treatment plan.</p>
<p><strong>Reference</strong></p>
<p>1. Myerson MS, Barouk P. The gastrocnemius. <em>Foot Ankle Clin N Am</em>. 2014; 19(4):603-858.</p>
</div></div></div>Tue, 19 May 2015 12:41:08 +0000Patrick DeHeer DPM FACFAS5047 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/why-it-important-evaluate-shoe-heel-toe-drop-patients-equinus#commentsRemoving Barriers To More DPMs Contributing To Published Podiatric Researchhttp://www.podiatrytoday.com/blogged/removing-barriers-more-dpms-contributing-published-podiatric-research
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>Hi, my name is Patrick and I have a problem. I am a digital article hoarder and my condition is getting worse. I have access to many journals through a large hospital system and I subscribe to several journals on my own. I recently joined the International Society of Biomechanics because it is a good organization but also so I could subscribe to <em>Clinical Biomechanics, Gait and Posture</em> and <em>The Journal of Biomechanics</em>. I was like a kid at Christmas as I claimed my online subscriptions. Giddy almost.</p>
<p>Like I said, I have a problem and I have no intention of fixing it. In fact, it will probably get worse as I have several articles I am in the process of writing and research projects I am working on or would like to start.</p>
<p>One article that is near submission and a research project I am about to start have led me to the conclusion that podiatry is lacking in published and cited peer-reviewed literature in comparison to our colleagues in orthopedics. When you critically examine citation indices regarding lower extremity orthopedics, podiatric articles lag behind orthopedic articles substantially.</p>
<p>There are several reasons for this. One reason is that orthopedic literature does not cite podiatric literature nearly as often as podiatric literature cites orthopedic literature. Prior to recent changes in podiatric employment models, most podiatric physicians have functioned as clinicians rather than researchers. There has been a welcome change in this paradigm with a growing number of podiatric physicians being employed by large universities and orthopedic groups. Finally, there is a growing interest and priority for evidence-based, high quality research in podiatric medicine.</p>
<p>I had to recently submit for an institutional review board (IRB) approval for the aforementioned research project. I have no experience in this process and I had to research how to do a research project. I received word that my research proposal was approved so apparently I did it correctly. This is an intimidating process for anyone without experience. There is also a substantial cost involved in the IRB application process.</p>
<p>Both of these factors are deterrents for the clinician trying to do research outside of a university setting. I believe there is a wealth of talent amongst my podiatric colleagues who have much to offer the world of orthopedic lower extremity research and peer-reviewed published articles, but we need to clear this path to bring this to fruition.</p>
<p>The American Podiatric Medical Association (APMA) has stepped to the forefront of this matter with the Dartmouth Institute (TDI) by establishing the APMA/TDI Public Health Fellowship with research positions at each of the podiatry schools for unmatched graduates and potential funding for research upon review by the APMA's Clinical Practice Review Committee. There have been many individuals who have led podiatric medicine into the field of research. Additionally, there is more emphasis from schools and residency programs on research.</p>
<p>Progress is happening but what I think is missing is a research resource with an affordable IRB process. This could potentially remove the deterrents that prevent many from contributing to the knowledge base. The question is who provides this for podiatric physicians? Would it be the APMA, the American Society of Podiatric Surgeons, the American College of Foot and Ankle Orthopedics and Medicine, or the American College of Foot and Ankle Surgeons? I do not know the answer but there should be one sooner rather than later.</p>
<p> </p>
<p> </p>
</div></div></div>Wed, 22 Apr 2015 12:44:20 +0000Patrick DeHeer DPM FACFAS4995 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/removing-barriers-more-dpms-contributing-published-podiatric-research#commentsWhy Equinus Is The Root Of All Foot Evilshttp://www.podiatrytoday.com/blogged/why-equinus-root-all-foot-evils
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>Equnius has been associated with 96.5 percent of all biomechanically-related lower extremity pathologies.<sup>1</sup> I have compiled a list of lower extremity pathologies (see below) that research has shown to have an equinus component along with the associated references.</p>
<p><strong>Lower extremity orthopedic pathologies related to equinus:</strong></p>
<p>Plantar heel pain/plantar fasciitis<sup>1-26</sup></p>
<p>Achilles tendonitis/tendonosis<sup>1,27-33</sup></p>
<p>Posterior tibial tendon dysfunction/adult flatfoot deformity<sup>2,8,25,26,32,34-42</sup></p>
<p>Muscle strains<sup>43</sup></p>
<p>Stress fractures<sup>31,44,45</sup></p>
<p>Shin splints/medial tibial stress syndrome<sup>31,44,46,47</sup></p>
<p>Iliotibial band syndrome<sup>44,46</sup></p>
<p>Patellofemoral syndrome<sup>48</sup></p>
<p>Ankle sprains/fractures<sup>49</sup></p>
<p>Diabetic foot ulcers<sup>25,26,50-56</sup></p>
<p>Charcot deformity<sup>55,57-60</sup></p>
<p>Metatarsalgia<sup>1,2,4,8,25,36,40,42</sup></p>
<p>Metatarsophalangeal synovitis/pre-dislocation syndrome<sup>8</sup></p>
<p>Hallux abducto valgus<sup>1,2,25,36,40,61-63</sup></p>
<p>Hammertoes/claw toes<sup>25,40,64</sup></p>
<p>Lisfranc/midfoot arthrosis<sup>25,41,65</sup></p>
<p>Hallux limitus/hallux rigidus<sup>7,40</sup></p>
<p>Forefoot calluses<sup>1,40</sup></p>
<p>Morton’s neuroma<sup>25,60,67</sup></p>
<p>Chronic ankle instability<sup>68</sup></p>
<p>Poor balance/increased fall rate in elderly<sup>69</sup></p>
<p>Sever’s disease<sup>70,71</sup></p>
<p>Pediatric flatfoot<sup>72,73</sup></p>
<p>Lateral foot pain<sup>1</sup></p>
<p>Genu recurvatum<sup>60</sup></p>
<p>Low back pain<sup>60</sup></p>
<p>Arch pain<sup>4</sup></p>
<p>Ankle arthrosis<sup>25,26</sup></p>
<p>Subtalar arthrosis<sup>25</sup></p>
<p>Sesamoiditis<sup>25</sup></p>
<p>Disclaimer: I am the inventor of the EQ/IQ equinus brace. To learn more about this device, please visit <a href="http://www.fixequinus.com">www.fixequinus.com</a> .</p>
<p><strong>References</strong></p>
<p>1. Hill RS. Ankle equinus. Prevalence and linkage to common foot pathology. <em>J Am Podiatr Med Assoc</em>. 1995; 85(6):295-300.</p>
<p>2. DiGiovanni CW, Kuo R, Tejwani N, et al. Isolated gastrocnemius tightness. <em>J Bone Joint Surg</em>. 2002; 84(6):962-970.</p>
<p>3. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. <em>Foot Ankle Int.</em> 2011; 32(1):5-8.</p>
<p>4. Maskill JD, Bohay DR, Anderson JG. Gastrocnemius recession to treat isolated foot pain. <em>Foot Ankle Int.</em> 2010; 31(1):19-23.</p>
<p>5. Singh D, Angel J, Bently G, Trevino SG. Fortnightly review: plantar fasciitis. <em>Br Med J.</em> 1997; 315(7101):172-175.</p>
<p>6. Kibler WB, Goldberg C, Chandler TJ. Functional biomechanical deficits in running athletes with plantar fasciitis. <em>Am J Sports Med</em>. 1991; 19(1):66-71.</p>
<p>7. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. <em>J Bone Joint Surg</em>. 2003; 85(5):872-877.</p>
<p>8. Stotler WM, Van Bergeyk A, Manoli A. Preliminary results of gastrocnemius recession in adults with nonspastic equinus contracture. Presented at American Orthopaedic Foot and Ankle Society 18th Annual Summer Meeting, Traverse City, Mich., 2002.</p>
<p>9. Powell M, Post WR, Keener J, Wearden S. Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study. <em>Foot Ankle Int. </em>1998; 19(1):10-18.</p>
<p>10. Wapner KL, Sharkey PF. The use of night splints for treatment of recalcitrant plantar fasciitis. <em>Foot Ankle Int.</em> 1991; 12(3):135-137.</p>
<p>11. Batt ME, Tanji JL, Skattum N. Plantar fasciitis: a prospective randomized clinical trial of the tension night splint. <em>Clin J Sports Med</em>. 1996; 6(3):158-162.</p>
<p>12. Lee WC, Wong WY, Kung E, Leung AK. Effectiveness of adjustable dorsiflexion night splint in combination with accommodative foot orthosis on plantar fasciitis. <em>J Rehabil Res Dev</em>. 2012; 49(10):1557-64.</p>
<p>13. Abbassian A, Kohls-Gatzoulis J, Solan MC. Proximal medial gastrocnemius release in the treatment of recalcitrant plantar fasciitis. <em>Foot Ankle Int.</em> 2012; 33(1):14-19.</p>
<p>14. Monteagudo M, Maceira E, Garcia-Virto V, Canosa R. Chronic plantar fasciitis: plantar fasciotomy versus gastrocnemius recession. <em>International Orthop</em>. 2013; 37(9):1845-1850.</p>
<p>15. Huerta JP. The effect of the gastrocnemius on the plantar fascia. <em>Foot Ankle Clin</em>. 2014; 19(4):701-718.</p>
<p>16. Beyzadeoglu T, Gokce A, Bekler H. The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis. <em>Acta Orthop Traumatol Tur</em>c. 2007; 41(3):220-224.</p>
<p>17. Solan MC, Carne A, Davies MS. Gastrocnemius shortening and heel pain. <em>Foot Ankle Clin.</em> 2014; 19(4):719-738.</p>
<p>18. Porter D, Barrill E, Oneacre K, May BD. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study. <em>Foot Ankle Int.</em> 2002; 23(7):619-624.</p>
<p>19. Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. <em>Foot Ankle Int.</em> 2013; 34(1):42-48.</p>
<p>20. Sheridan L, Lopez A, Perez A, et al. Plantar fasciopathy treated with dynamic splinting: a randomized controlled trial. <em>J Am Podiatr Med Assoc</em>. 2010; 100(3):161-165.</p>
<p>21. DiGiovanni BF, Moore AM, Zlotnicki JP, Pinney SJ. Preferred management of recalcitrant plantar fasciitis among orthopaedic foot and ankle surgeons. <em>Foot Ankle Int.</em> 2012; 33(6):507-512.</p>
<p>22. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. <em>Foot Ankle Int.</em> 1994; 15(10):531-535.</p>
<p>23. Labovitz J, Yu J, Kim C. The role of hamstring tightness in plantar fasciitis. <em>Foot Ankle Spec. </em>2011; 4(3):141-4.</p>
<p>24. Flanigan RM, Nawoczenski DA, Chen L, et al. The influence of foot position on stretching of the plantar fascia. <em>Foot Ankle Int.</em> 2007; 28(7):815-822.</p>
<p>25. Phisitkul P, Rungprai C, Femino JC, et al. Endoscopic gastrocnemius recession for the treatment of isolated gastrocnemius contracture a prospective study on 320 consecutive patients. <em>Foot Ankle Int.</em> 2014; 35(8):747-56.</p>
<p>26. Chen L, Greisberg J. Achilles lengthening procedures. <em>Foot Ankle Clin</em>. 2009; 14(4):627-637.</p>
<p>27. Verrall, Geoffrey, Schofield S, Brustad T. Chronic Achilles tendinopathy treated with eccentric stretching program. <em>Foot Ankle Int</em>. 2011; 32(9):843-849.</p>
<p>28. Amis J. The gastrocnemius: a new paradigm for the human foot and ankle. <em>Foot Ankle Clin.</em> 2014; 19(4):637-647.</p>
<p>29. Gurdezi S, Kohls-Gatzoulis J, Solan MC. Results of proximal medial gastrocnemius release for Achilles tendinopathy. <em>Foot Ankle Int. </em>2013; 34(10):1364-1369.</p>
<p>30. Kaufman KR, Brodine SK, Shaffer RA, et al. The effect of foot structure and range of motion on musculoskeletal overuse injuries. <em>Am J Sports Med</em>. 1999; 27(5):585–593.</p>
<p>31. Wilder RP, Sethi S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. <em>Clin Sports Med</em>. 2004; 23(1):55–81.</p>
<p>32. Lamm BM, Paley D, Herzenberg JE. Gastrocnemius soleus recession: a simpler, more limited approach. <em>J Am Podiatr Med Assoc</em>. 2005;95(1):18–25.</p>
<p>33. Kiewiet NJ, Holthusen SM, Bohay DR, Anderson JG. Gastrocnemius recession for chronic noninsertional Achilles tendinopathy. <em>Foot Ankle Int</em>. 2013; 34(4):481-5.</p>
<p>34. Alvarez RG, Marini A, Schmitt C, Saltzman CL. Stage I and II posterior tibial tendon dysfunction treated by a structured nonoperative management protocol: an orthosis and exercise program. <em>Foot Ankle Int</em>. 2006; 27(1):2-8.</p>
<p>35. Aronow MS. Triceps surae contractures associated with posterior tibial tendon dysfunction. <em>Techniques Orthopaedics</em>. 2000; 15(3):164-173.</p>
<p>36. Downey MS, Banks AS. Gastrocnemius recession in the treatment of nonspastic ankle equinus: a retrospective study. <em>J Am Podiatr Med Assoc</em>. 1989; 79(4):159–174.</p>
<p>37. Harris RI, Beath T. Hypermobile flatfoot with short tendo Achilles. <em>J Bone Joint Surg</em>. 1948; 30(1):116–141.</p>
<p>38. Hibbs RA. Muscle bound feet. <em>NY Med J</em>. 1914; 17(3):797–799.</p>
<p>39. Hoke M. An operation for the correction of extremely relaxed flat feet. <em>J Bone Joint Surg</em>. 1931; 13(1):773–784.</p>
<p>40. Sgarlato TE, Morgan J, Shane HS, Frenkenberg A. Tendo Achilles lengthening and its effect on foot disorders. <em>J Am Podiatr Med Asso</em>c. 1975; 65(9):849–871.</p>
<p>41. Hansen ST Jr. <em>Functional Reconstruction of the Foot and Ankle</em>, Lippincott Williams &amp; Wilkins, Philadelphia, 2000.</p>
<p>42. Subotnick SI. Equinus deformity as it affects the forefoot. <em>J Am Podiatry Assoc</em>. 1971; 61(11):423–427.</p>
<p>43. Ekstrand J, Gillquist J. The frequency of muscle tightness and injuries in soccer players. <em>Am J Sports Med.</em> 1982; 10(1):75–78.</p>
<p>44. Neely FG. Biomechanical risk factors for exercise-related lower limb injuries. <em>Sports Med</em>. 1998; 26(6):395–413.</p>
<p>45. Fredericson M. Common injuries in runners. Diagnosis, rehabilitation and prevention. <em>Sports Med.</em> 1996;21(1):49-72.</p>
<p>46. Messier SP, Pittala KA. Etiologic factors associated with selected running injuries. <em>Med Sci Sports Exerc</em>. 1988; 20(5):501–505.</p>
<p>47. Lilletvedt J, Kreighbaum E, Phillips RL. Analysis of selected alignment of the lower extremity related to the shin splint syndrome. <em>J Am Podiatry Assoc.</em> 1979; 69(3):211-217.</p>
<p>48. Lun V, Meeuwisse WH, Stergiou P, Stefanyshyn D. Relation between running injury and static lower limb alignment in recreational runners. <em>Brit J Sports Med</em>. 2004; 38(5):576–580.</p>
<p>49. Tabrizi P, McIntyre WM, Quesnel MB, Howard, AW. Limited dorsiflexion predisposes to injuries of the ankle in children. <em>J Bone Joint Surg</em>. 2000; 82(2):1103–1106.</p>
<p>50. Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkness LB. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot. <em>J Bone Joint Surg</em>. 1999; 81(4):535–538.</p>
<p>51. Barry DC, Sabacinski KA, Habershaw GM, et al. Tendo Achilles procedures for chronic ulcerations with transmetatarsal amputations. <em>J Am Podiatr Med Assoc</em>. 1993; 83(2):96–100.</p>
<p>52. Lin SS, Lee TH, Wapner, KL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting. <em>Orthopedics</em>. 1996; 19(5):465–475.</p>
<p>53. Mueller MJ, Sinacore DR, Hastings MK, et al. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. <em>J Bone Joint Surg</em>. 2003; 85-A(8):1436–1445.</p>
<p>54. Nishimoto GS, Attinger CE, Cooper PS. Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration. <em>Surg Clin North Am</em>. 2003; 83(3):707–726.</p>
<p>55. Grant WP, Sullivan R, Sonenshine DE, et al. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. <em>J Foot Ankle Surg</em>. 1997; 36(4):272–278, discussion 330.</p>
<p>56. Lavery LA, Armstrong DG, Boulton AJ. Ankle equinus deformity and its relationship to high plantar pressure in a large population with diabetes mellitus.<em> J Am Podiatr Med Asso</em>c. 2002; 92(9):479–482.</p>
<p>57. Early JS, Hansen ST. Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse. <em>Foot Ankle Int</em>. 1996; 17(6):325–330.</p>
<p>58. Schon LC, Easley ME, Weinfeld SB. Charcot neuroarthropathy of the foot and ankle. <em>Clin Orthop</em>. 1998; 349:116–131.</p>
<p>59. Banks AS, McGlamry ED. Charcot foot. <em>J Am Podiatr Med Assoc.</em> 1989; 79(5):213–235.</p>
<p>60. Downey MS. Ankle Equinus. In Banks AS, Downey MS, Martin DE, Miller SJ (eds.) <em>McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery</em>, Lippincott Williams &amp; Wilkins, Philadelphia, 2001, pp. 715–760.</p>
<p>61. Hansen ST Jr. Hallux valgus surgery. Morton and Lapidus were right. <em>Clin Podiatr Med Surg</em>. 1996; 13(3):347–354.</p>
<p>62. Holstein A. Hallux valgus—an acquired deformity of the foot in cerebral palsy. <em>Foot Ankle Int.</em> 1980; 1(1):33-38.</p>
<p>63. Barouk LS. The effect of gastrocnemius tightness on the pathogenesis of juvenile hallux valgus: a preliminary study. <em>Foot Ankle Clin.</em> 2014; 19(4):807-822.</p>
<p>64. Green DR, Ruch JA, McGlamry ED. Correction of equinus-related fore- foot deformities: a case report. <em>J Am Podiatry Assoc.</em> 1976; 66(10):768–780.</p>
<p>65. Nemec SA, Habbu RA, Anderson JG, Bohay DR. Outcomes following midfoot arthrodesis for primary arthritis. <em>Foot Ankle Int.</em> 2011; 32(4):355-361.</p>
<p>66. Maceira E, Monteagudo M. Functional hallux rigidus and the Achilles-calcaneus-plantar system. <em>Foot Ankle Clin</em>. 2014; 19(4):669-699.</p>
<p>67. Root ML, Orien WP, Weed JH. Forces acting upon the foot during locomotion: abnormal motion of the foot. In <em>Normal and Abnormal Function of the Foot, Clinical Biomechanics</em>, Vol 2, Clinical Biomechanics Corp., Los Angeles, 1977, pp. 165–179, 295.</p>
<p>68. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. <em>Aust J Physiother.</em> 1998;44(3):165-172.</p>
<p>69. Gajdosik RL, Vander Linden DW, McNair PJ, et al. Effects of an eight-week stretching program on the passive-elastic properties and function of the calf muscles of older women. <em>Clin Biomech (Bristol, Avon).</em> 2005, 20(9):973–983.</p>
<p>70. Becerro de Bengoa Vallejo R, Losa Iglesias ME, Rodríguez Sanz D, et al. Plantar pressures in children with and without Sever’s disease. <em>J Am Podiatr Med Assoc.</em> 2011; 101(1):17-24.</p>
<p>71. Szames SE, Forman WM, Oster J, et al. Sever's disease and its relationship to equinus: a statistical analysis. <em>Clin Podiatr Med Surg</em>. 1990; 7(2):377-384.</p>
<p>72. Reimers J, Pedersen B, Brodersen A. Foot deformity and the length of the triceps surae in Danish children between 3 and 17 years old. <em>J Pediatr Orthop B</em>. 1995; 4(1):71-73.</p>
<p>73. DiGiovanni CW, Langer P. The role of isolated gastrocnemius and combined Achilles contractures in the flatfoot. <em>Foot Ankle Clin.</em> 2007; 12(2):363-379.</p>
<p><strong>Additional References</strong></p>
<p>74. Lundgren P, Nester C, Liu A, et al. Invasive in vivo measurement of rear-, mid-and forefoot motion during walking. <em>Gait Posture</em>. 2008; 28(1):93-100.</p>
<p>75. Evans AM, Scutter SD. Sagittal plane range of motion of the pediatric ankle joint: a reliability study. <em>J Am Podiatr Med Assoc</em>. 2006; 96(5):418-422.</p>
<p>76. Gourdine-Shaw MC, Lamm BM, Herzenberg JE, Bhave A. Equinus deformity in the pediatric patient: Causes, evaluation, and management. <em>Clin Podiatr Med Surg</em>. 2010; 27(1):25-42.</p>
<p> </p>
</div></div></div>Wed, 08 Apr 2015 12:46:26 +0000Patrick DeHeer DPM FACFAS4975 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/why-equinus-root-all-foot-evils#commentsAre We Facing The Death Of The Austin Bunionectomy?http://www.podiatrytoday.com/blogged/are-we-facing-death-austin-bunionectomy
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>It is a rarity when a revolutionary idea that has the backing of evidence-based medicine challenges a long-held belief, but this is what leads to a paradigm shift resulting in a major breakthrough in medicine.</p>
<p>Paul Dayton, DPM, has led a paradigm shift in bunion surgery with the substantial work he and his group have compiled over the past several years and brought it full circle in their recent article “Is Our Current Paradigm for Evaluation and Management of the Bunion Deformity Flawed? A Discussion of Procedure Philosophy Relative to Anatomy” in the <em>Journal of Foot and Ankle Surgery</em>.<sup>1</sup> I believe this paradigm shift in fact is the death of the Austin bunionectomy or at least it should be. </p>
<p>I have done hundreds if not thousands of Austin bunionectomies over my career. I have over the past five years or so gradually drifted away from the Austin. My procedures of choice for hallux abucto valgus have become either first metatarsophalangeal joint (MPJ) arthrodesis or first metatarsocuneiform arthrodesis. The first metatarsocuneiform arthrodesis is a technically demanding procedure that can be fraught with complications, mostly iatrogenic. However, after reading and listening to Dayton’s theory, it is clearly the most appropriate choice for deformity correction in hallux abducto valgus if first MPJ arthrodesis is not appropriate.</p>
<p>The basis of Dayton’s premise is twofold, focusing on the center of rotation of angulation (CORA) location and the triplane nature of hallux abducto valgus. Numerous surgeons have shown the CORA to be located at the metatarsocuneiform joint.<sup>1-7</sup> This is a critical consideration as translational osteotomies of the head, midshaft or base are all distal to the CORA or as Dayton states, “Instead these popular procedures have focused correction on a non-deformed metatarsal with the singular priority of reducing the (intermetatarsal angle).”<sup>1</sup></p>
<p>The frontal plane deformity of the first metatarsal in hallux abucto valgus is a complex, underappreciated component of the deformity that led Dayton and his colleagues to their conclusions of our current state of bunion correction.<sup>1</sup> They have shown in conjunction with others the valgus rotation of the first metatarsal occurring at the first metatarsocuneiform joint is at least partially responsible for the sesamoid malalignment, not solely transverse plane deformity as previously thought.<sup>5-7</sup> Studies have shown that the perceived abnormal position of the sesamoids on an AP X-ray view do not correlate with axial sesamoid views showing the sesamoids to be in their grooves separated by the median cristae.<sup>5-7</sup> With valgus rotation, the tibial sesamoid position and dorsal medial eminence worsen, but varus rotation of the first metatarsal reduces the tibial sesamoid position and the dorsal medial eminence.</p>
<p>What about all those Austin bunionectomies with the sesamoids centered beneath the metatarsal head postoperatively? Dayton suggests “iatrogenic subluxation of the sesamoids medial to the median crista has created the perception that the sesamoids are correctly positioned under the metatarsal on the AP radiograph … after the lateral release and during the medial capsular plication.” Alternately, Dayton notes “in some cases a degree of frontal plane correction occurs spontaneously when retrograde buckling forces of the hallux acting on the metatarsal are relieved.”<sup>1</sup> Over time, there is a resultant lateral drift of the sesamoids.</p>
<p>The only surgical method that addresses both the CORA and frontal plane component of the triplanar hallux abducto valgus deformity is first metatarsocuneiform arthrodesis. This procedure is not an easy one to get consistent positional results but evidence-based medicine shows we must refine our techniques not only to correct the transverse and sagittal planes, but the frontal plane as well. It appears that at long last and after hundreds of procedures, there is finally a definitive answer for hallux abducto valgus.</p>
<p><strong>References</strong></p>
<ol><li>Dayton P, Kauwe M, Feilmeier M. Is our current paradigm for evaluation and management of the bunion deformity flawed? A discussion of procedure philosophy relative to anatomy. <em>J Foot Ankle Surg.</em> 2015; 54(1):102-111.</li>
<li>Paley D, Herzenber JE. <em>Principles of Deformity Correction</em>, Springer-Velag, Berlin, 2005.</li>
<li>Dayton P, Feilmeier M, Kauwe M, Hirschi J. Relationship of frontal plane rotation of first metatarsal to proximal articular set angle and hallux alignment in patients undergoing tarsal metatarsal arthrodesis for hallux abducto valgus: a case series and critical review of the literature. <em>J Foot Ankle Surg</em>. 2013; 52(3):348–354.</li>
<li>DiDomenico LA, Fahim R, Rollandini J, Thomas ZM. Correction of frontal plane rotation of sesamoid apparatus during Lapidus procedure: a novel approach. <em>J Foot Ankle Surg</em>. 2014; 53(2):248–251.</li>
<li>Dayton P, Feilmeier M, Hirschi J, Kauwe M, Kauwe JS. Observed changes in radiographic measurements of the first ray after frontal plane rotation of the first metatarsal in a cadaveric foot model. <em>J Foot Ankle Surg</em>. 2014; 53(3):274–278.</li>
<li>Dayton P, Feilmeier M, Hirschi J, Kauwe M, Kauwe JS. Observed changes in radiographic measurements of the first ray after frontal plane rotation of the first metatarsal in a cadaveric foot model. <em>J Foot Ankle Surg</em>. 2014; 53(3):274–278.</li>
<li>Dayton P, Kauwe M, Feilmeier M. Clarification of the anatomic definition of the bunion deformity. <em>J Foot Ankle Surg</em>. 2014; 53(2):160–163.</li>
</ol><p><em>Editor’s note: For a related article, look for “</em><em>Addressing The Impact Of Frontal Plane Rotation On Bunion Repair” by Lawrence A. DiDomenico, DPM, FACFAS, and Frank A. Luckino III, DPM, AACFAS, in the forthcoming April 2015 issue of Podiatry Today. </em></p>
</div></div></div>Tue, 10 Mar 2015 12:13:40 +0000Patrick DeHeer DPM FACFAS4931 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/are-we-facing-death-austin-bunionectomy#commentsMy Vision For The APMA Board Of Trusteeshttp://www.podiatrytoday.com/blogged/my-vision-apma-board-trustees
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>I will be running for American Podiatric Medical Association (APMA) Board of Trustees in March at the APMA House of Delegates in Washington, D.C. I look forward to the campaign and would ask you for your support. You can support my campaign by contacting your state delegates and letting them know of your support for my candidacy.</p>
<p>My 2015 campaign for the Board of Trustees focuses on four things:</p>
<p>1. Continuing a lifetime commitment to advancing podiatry’s future</p>
<p>2. Intense dedication to progressive, global, podiatric academia</p>
<p>3. A pledge to wholly transparent stewardship</p>
<p>4. Applying my vast experience in local, state and national podiatric governance</p>
<p>I truly believe the APMA is a strong organization and I would like the honor of participating directly in its continued excellence. It is only when an organization operates strategically that it will serve as a powerful resource to its members and the interests it represents. I am committed to building upon the APMA’s proud foundation. I vow to work every day to be accountable, transparent and accessible to all APMA members as a trustee.</p>
<p>There are a variety of issues that I think are important and require either continued oversight or APMA intervention.</p>
<p>· Passage of the Helping Ensure Life- and Limb-Saving Access to Podiatric Physicians (HELLPP) Act. This will continue the path towards parity for podiatric physicians.</p>
<p>· Permanent fix for the Sustainable Growth Rate. This will take the fear out of substantial pay cuts for podiatric physicians and remove the anxiety of temporary fixes to a broken system.</p>
<p>· Residency genesis. No qualified podiatric medical school graduate should go without a residency. Much progress has occurred with this topic but there is still work to do.</p>
<p>· Common sense approach to Meaningful Use documentation. Physicians are under enormous pressure in patient documentation so there must be a re-examination of this and implementation of a more logical, efficient, physician-friendly plan.</p>
<p>· Transparent and continued growth of the APMA. This will enable and support APMA members’ professional careers.</p>
<p>· Promoting evidenced-based research in support of podiatric medicine. This includes studies like the Thomson Reuters, Arizona Medicaid and Duke studies.<sup>1-3</sup></p>
<p>· Continued engagement of the young physician group. The future of the profession is the young physician group and the APMA has done an outstanding job of engaging this group and empowering them. This program must continue and develop.</p>
<p><strong>A Review Of Qualifications</strong></p>
<p>My career highlights and qualifications as a candidate for the APMA Board of Trustees are as follows:</p>
<p>· International Federation of Podiatrists Humanitarian of the Year, 2014</p>
<p>· American Podiatric Medical Association Humanitarian of the Year, 2011</p>
<p>· T.H. Clarke Achievement Award-Indiana Podiatric Medical Association, 2011</p>
<p>· Earl G. Kaplan Memorial Lecture Award-Michigan Podiatric Medical Association, 2015</p>
<p>· President and Founder of Step-by-Step Haiti non-profit organization</p>
<p>· Principal of Hoosier Foot and Ankle</p>
<p>· APMA Political Action Committee Board of Directors</p>
<p>· American Society of Podiatric Surgeons Board of Directors</p>
<p>· American College of Foot and Ankle Pediatrics Board of Directors</p>
<p>· Indiana Podiatric Medical Association Past President, 2012-2013</p>
<p>· Meritorious Service Award from Indiana Podiatric Medical Association, 2000 and 2004</p>
<p>· Over 25 medical missionary trips worldwide</p>
<p>· American Podiatric Medical Association Finance Committee, Resolutions Committee, Clinical Advisory Committee</p>
<p>· Team podiatrist for the Indiana Pacers and Indiana Fever</p>
<p>· Published author</p>
<p>· Guest Editor for <em>Clinics in Podiatric Medicine and Surgery, </em>Pediatrics Volume</p>
<p>· Guest Editor for <em>Foot and Ankle Quarterly</em>, Clubfoot Volume</p>
<p>· Editorial Board member and DPM Blogger for <em>Podiatry Today</em></p>
<p>· Diplomate, American Board of Foot and Ankle Surgery (ABFAS) - Certified Foot, Reconstructive Rearfoot and Ankle</p>
<p>· Fellow of the American Board of Podiatric Surgery</p>
<p>· Fellow of the American College of Foot and Ankle Surgeons</p>
<p>My wife, Erika, and I enjoy spending time with our six children, Sarah, Joey, Jack, Josh, Alex and Brian, who range in age from 28 to 15. We also have three dogs, one horse and one goat. I enjoy traveling, running, playing golf, Indianapolis Colts football, Indiana University basketball, reading, movies, listening to live music with Erika, and watching vintage movies of my father playing basketball for Indiana University.</p>
<p>If you have any questions regarding my candidacy, please email me at <a href="mailto:padeheer@sbcglobal.net">padeheer@sbcglobal.net</a> . I would love to speak with you regarding my vision for the APMA. My campaign website is <a href="http://www.indianapodiatric.org/patdeheer.html">http://www.indianapodiatric.org/patdeheer.html</a> , where you can view my complete CV. Thank you for your consideration.</p>
<p><strong>References</strong></p>
<p>1. Carls GS, Gibson TB, Driver VR, et al. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. <em>J Am Podiatr Med Assoc</em>. 2011; 101(2):93-115.</p>
<p>2. Skrepnek GH, Mills JL, Armstrong DG. Foot-in-wallet disease: tripped up by ‘cost-saving’ reductions? <em>Diabetes Care</em>. 2014; 37(9):e196-7. </p>
<p>3. Sloan FA, Feinglos MN, Grossman DS. Receipt of care and reduction of lower extremity amputations in a nationally representative sample of US elderly.<em> Health Serv Res</em>. 2010; 45(6 pt1):1740-62.</p>
</div></div></div>Thu, 29 Jan 2015 13:46:55 +0000Patrick DeHeer DPM FACFAS4868 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/my-vision-apma-board-trustees#commentsWhy All Peer-Reviewed Journals Should Be Open Accesshttp://www.podiatrytoday.com/blogged/why-all-peer-reviewed-journals-should-be-open-access
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>The philanthropist Bill Gates is someone I admire very much because he is making a difference in the world, particularly in developing countries. As of January 1, 2015 the Bill and Melinda Gates Foundation will require all peer-reviewed published research either fully or partially funded by the foundation to be published in open access journals. There is a two-year transition for this to occur, but by 2017 the 12-month embargo period to allow journals to charge for articles will lift and open access to peer-reviewed published articles funded by the foundation must be immediate.</p>
<p>The Gates Foundation website states, “We believe that published research resulting from our funding should be promptly and broadly disseminated.”<sup>1</sup> I say bravo to Mr. and Mrs. Gates! Thank you.<br />
After this was published in the media, I started thinking in today’s digital age, why aren’t all peer-reviewed medical journals open access? I subscribe to several journals, some of which are included in my membership dues (the <em>Journal of Foot and Ankle Surgery</em> for the American College of Foot and Ankle Surgeons, the <em>Journal of the American Podiatric Medical Association</em> for the American Podiatric Medical Association) and some I pay to subscribe to (<em>Foot and Ankle International, Foot and Ankle Specialist</em>, the <em>Journal of Bone and Joint Surgery</em>). These subscription journals are not particularly cheap but I think they are important for my career and invest in them. There are others I would like to have access to such as <em>Clinical Biomechanics,</em> the <em>Journal of Pediatric Orthopedics</em>, <em>Advances in Skin and Wound Care</em> and the <em>American Journal of Sports Medicine</em>, but I have limited funds for journal subscriptions so I pick and choose the journals that will provide me with the most useful information.</p>
<p>I prefer to have digital copies of articles I can save in my library for future reference after reading them. I have also advertised for various reasons in journals, both in print and online, so I have an idea of the type of revenue advertising generates. I fully understand there are costs with printing and mailing journals, and even costs associated with an online journal. However, at what point does advertising revenue offset the production costs for a digital journal?</p>
<p>This leads to the next logical question: why are all peer-reviewed journals not open access? I think as print media dies out and digital media completely takes over, this question becomes even more relevant.</p>
<p>In the modern world of evidence-based medicine, it seems that information published in peer-reviewed journals must be open access from a “what is best for society” standpoint. We want to provide the best medical care to our patients based on valid research but we need access to the research to gain the knowledge to provide said care.</p>
<p>I often can find and get the articles that I want but I do not have immediate access. I am on staff at a hospital that has libraries that allow me access to most journals I do not subscribe to. The problem is I do not always see the contents of these journals — which are pertinent to my profession but to which I do not subscribe — to pick and choose which articles I would like to read. I am pretty diligent about combing through searches for lecture and article preparation so I eventually stumble upon most of the articles I would like to read. I would suspect that most medical professionals do not comb the literature as much and miss a significant amount of valuable information that could significantly impact their practices.</p>
<p>It seems to me that content generated for free and peer-reviewed for free in a journal with advertising revenue should be available for free. As the Gates Foundation website states, “With an open exchange of information and ideas, we can better assess evidence, identify opportunities, build trust and learn for each other’s experiences.”<sup>1</sup></p>
<p><strong>Reference</strong></p>
<ol><li>Available at <a href="http://www.gatesfoundation.org/How-We-Work/General-Information/Open-Access-Policy">http://www.gatesfoundation.org/How-We-Work/General-Information/Open-Access-Policy</a> .</li>
</ol><p> </p>
<p> </p>
<p> </p>
<p> </p>
</div></div></div>Tue, 06 Jan 2015 13:53:59 +0000Patrick DeHeer DPM FACFAS4811 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/why-all-peer-reviewed-journals-should-be-open-access#commentsCrucial Questions About Treating Plantar Fasciitis In Obese Patientshttp://www.podiatrytoday.com/blogged/crucial-questions-about-treating-plantar-fasciitis-obese-patients
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>I had the opportunity to speak recently at the American Public Health Association meeting in New Orleans for the podiatry section. I would highly encourage everyone to consider joining this organization as I believe the natural symbiotic relationship between podiatry and public health is an important one. One of the two topics I spoke on was “Obesity and Plantar Fasciitis.” </p>
<p>There is a definite association between obesity and plantar fasciitis that those who treat heel pain everyday know instinctively. Obesity is the greatest cause of morbidly and mortality worldwide.<sup>1</sup> Research has shown that weight loss reduces this morbidity and mortality.<sup>2</sup> Approximately 34 percent of the adult population in the United States is obese and 68 percent is overweight.<sup>3</sup> The problem is getting worse and is also affecting our youth at historic rates.</p>
<p>Systematic literature reviews suggests that long-term weight loss through changes in eating and physical activity is possible.<sup>4</sup> Unfortunately, weight loss from behavioral changes typically maximizes approximately six months into the weight loss attempt, followed by a gradual regain of weight in most individuals.<sup>5</sup> Maintaining weight loss is critical to sustain health benefits so understanding how best to support patients in sustaining weight loss is vital to addressing the obesity epidemic and its consequences.<sup>6,7</sup></p>
<p>There are well-documented gait changes associated with obesity that include shorter steps, slower gait, increased step width, greater ankle joint dorsiflexion, less ankle joint plantarflexion, increased Q-angles, increased hip abduction angles, increased foot abduction angles, increased out-toeing and increased pronation during midstance.<sup>8-11</sup></p>
<p>In 2007, Frey and Zamora examined orthopedic-related foot and ankle pathologies and the influence of obesity in 1,411 patients.<sup>12</sup> They found there was a 1.4 times greater incidence of plantar fasciitis in obese patients, namely those having a body mass index (BMI) = 25. Additionally, Tanamas and colleagues in 2012 showed a statistically significant relationship between increased BMI and foot pain, and between increased fat-mass index and foot pain.<sup>13</sup> In 2007, Irving and coworkers did a case-matched control study, showing that patients with chronic plantar heel pain were 2.9 times more likely to have a BMI = 30.<sup>14</sup></p>
<p>This evidenced-based medicine supports the intuition that there is a direct correlation between obesity and plantar fasciitis. There are some questions that we must answer in the treatment of obese patients with plantar fasciitis.</p>
<p>1. Should treatment be more aggressive to resolve the condition as quick as possible?</p>
<p>2. If so, how does an aggressive, rapid result treatment plan correlate to established treatment protocols?</p>
<p>3. What is the role of surgical intervention and when should you perform it?</p>
<p>4. How can we promote exercising with a painful heel(s)?</p>
<p>5. What is podiatry’s role in obesity counseling and treatment?</p>
<p>6. What is the role of weight loss in plantar fasciitis treatment?</p>
<p>Prior to answering these questions, we must clarify the goal of treatment. I believe the goal of treatment in the patient is to initiate or continue an exercise regimen that will allow obese patients with plantar fasciitis to lose weight as efficiently as possible and maintain weight loss in the long term.</p>
<p>I do advise a more aggressive approach to treatment in this patient. I believe initial therapy should focus on symptom (oral and/or injected steroids) and etiology (external support via taping and stretching via bracing therapy, appropriate shoe gear) treatment simultaneously, and use the pain scale to monitor therapy. If pain reduction is resolving as expected, continue standard therapies that have been well documented in the literature. If the patient plateaus or regresses, add adjunctive therapies (physical therapy, shockwave, immobilization, platelet rich plasma injection, amniotic membrane injection, etc.) to the treatment plan to aid in pain reduction. Once pain resolution occurs, long-term therapy should start with continued stretching and custom orthoses.</p>
<p>If a patient does not respond to conservative therapy (which research has shown to be effective approximately 85 percent of the time) within an appropriate time period (usually six months), surgical intervention may become an option.<sup>15</sup> Should an obese patient who is trying to lose weight with exercise but is not responding to conservative therapy have to wait six months for surgery? Can waiting be detrimental to a weight loss program? What can this failure mean to the patient’s psyche about his or her weight?</p>
<p>I certainly believe in appropriate conservative therapy but I think it becomes a more individualized patient-physician decision with lack of progress. A time period for one patient may not be adequate for another patient. Prior to any surgical intervention, I get a magnetic resonance image (MRI) to rule out Baxter’s nerve entrapment. If this is negative, I have gone to a gastrocnemius recession in lieu of a plantar fasciotomy. The plantar fascia is critical to arch stability and cutting it comes with consequences such as lateral column pain due to pronatory changes. This is particularly concerning in the obese patients and avoidance of cutting of the plantar fascia is of utmost importance. There is evidenced-based medicine to support gastrocnemius recession for plantar fasciitis.<sup>16</sup></p>
<p>There are some even larger considerations that must accompany treatment of this patient, either conservatively or surgically. Consider several referrals including primary care physician, nutritionist/dietitian, bariatric surgery, personal trainer and physiatrist consultations. Any of these consultations require open, honest, compassionate conversation with the patient about obesity.</p>
<p>It is our job to aid the obese patients with plantar fasciitis in recovering as quickly as possible to aid in their weight loss, which will decrease their morbidity and mortality.</p>
<p><strong>References</strong></p>
<p>1. Haslam DW, James, WP. Obesity. <em>Lancet</em>. 2005; 366(9492):1197–209.</p>
<p>2. Poobalan AS, Aucott LS, Smith WC, et al. Long-term weight loss effects on all cause mortality in overweight/obese populations. <em>Obesity Rev</em>. 2007; 8(6):503-513.</p>
<p>3. Available at</p>
<p><a href="http://www.hivehealthmedia.com/world-obesity-stats-2010/">http://www.hivehealthmedia.com/world-obesity-stats-2010/</a><u> .</u></p>
<p>4. Avenell A, Broom J, Brown TJ, et al. Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. <em>Health Technol Assess.</em> 2004; 8(21):1-182.</p>
<p>5. Dombrowski SU, Avenell A, Sniehott FF. Behavioural interventions for obese adults with additional risk factors for morbidity: systematic review of effects on behaviour, weight and disease risk factors. <em>Obesity Facts</em>. 2010; 3(6):377-396.</p>
<p>6. Penn L, White M, Lindstrom J, et al. Importance of weight loss maintenance and risk prediction in the prevention of type 2 diabetes: analysis of European Diabetes Prevention Study RCT. <em>PloS One</em>. 2013; 8(2):e57143.</p>
<p>7. Dombrowski SU, Knitt K, Avenell A, et al. Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomised controlled trials. <em>BMJ</em>. 2014; epub ahead of print.</p>
<p>8. Petrella RJ, Bartha C. Home based exercise therapy for older patients with knee osteoarthritis: a randomized clinical trial. <em>J Rheumatol</em>. 2000; 27(9):2215-2221.</p>
<p>9. Sharma L, Lou C, Cahue S, Dunlop DD. The mechanism of the effect of obesity in knee osteoarthritis: the mediating role of malalignment. <em>Arthritis Rheum</em>. 2000; 43(3):568-575.</p>
<p>10. Toda Y, Segal N, Kato A, et al. Correlation between body composition and efficacy of lateral wedged insoles for medial compartment osteoarthritis of the knee. <em>J Rheumatol</em>. 2002; 29(3):541-545.</p>
<p>11. Toda Y. The effect of energy restriction, walking, and exercise on lower extremity lean body mass in obese women with osteoarthritis of the knee. <em>J Orthop Sci</em>. 2001; 6(2):148-54.</p>
<p>12. Frey C, Zamora J. The effects of obesity on orthopaedic foot and ankle pathology. <em>Foot Ankle Int</em>. 2007; 28(9):996-999.</p>
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</div></div></div>Thu, 04 Dec 2014 13:45:15 +0000Patrick DeHeer DPM FACFAS4732 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/crucial-questions-about-treating-plantar-fasciitis-obese-patients#commentsDo Podiatrists Face Less Discrimination From Orthopedic Surgeons These Days?http://www.podiatrytoday.com/blogged/do-podiatrists-face-less-discrimination-orthopedic-surgeons-these-days
<div class="field field-name-body field-type-text-with-summary field-label-hidden"><div class="field-items"><div class="field-item even" property="content:encoded"><p>I am involved with two residency programs in the Indianapolis area as an attending foot and ankle surgeon. The residents primarily do surgery with me and occasionally come to my office as well. I have long enjoyed teaching both residents and students over the course of my career. I have always thought it was imperative to give back to those coming up and share my knowledge and experience as those ahead of me have done. I believe the training you receive during your residency more often than not sets the stage for your entire career. I also understand that we all have different levels of comfort in our teaching styles. For example, some are more inclined than others to “hand over the knife” in surgery. </p>
<p>The other thing I have noticed over the years being involved with the residency programs is the participation of orthopedics in the training of podiatric residents, which has been mostly positive. Dating back to my residency, my involvement with orthopedic surgeons was primarily assisting on their knee, hip, shoulder and trauma cases with an occasional foot case sprinkled in. I have seen the residents’ training over the years become more involved with orthopedics and I think that is a great thing. The more exposure young physicians have during training, the more rounded they become.</p>
<p>It has gotten to the point that in one of the programs here, the residents work closely with a foot and ankle orthopedic surgeon. I asked the orthopedic surgeon to lecture at our state conference this month to try to build some bridges with the orthopedic foot and ankle community in central Indiana. He agreed and the audience received his lectures well, and I felt that he had indeed built some bridges. His participation with podiatric residency training opened a door and I took advantage of that.</p>
<p>There is a very interesting dynamic because I would say the relationship between foot and ankle orthopedic surgeons and podiatry in central Indiana has been pretty much awful. There has been tremendous conflict that essentially stems from the large orthopedic group that dominates central Indiana, specifically its foot and ankle orthopedic surgeons. Although the foot and ankle orthopedic surgeon who works alongside of the podiatry residency program is not part of this group, I have been encouraged by what I consider progress.</p>
<p>Recently, the orthopedic surgeon and I both proctored a cadaver workshop for the residents and students from the one residency program he works with directly. He does not go to the other hospital that has a podiatric residency program and therefore those residents unfortunately do not get to work with him. I was even more encouraged watching him fully engaged in teaching the podiatric residents and students. It is obvious he really cares about their education. The sad part of all this is he is scheduled to retire next fall.</p>
<p>The flipside of this story is the other podiatric residency program in Indianapolis. This program is in a much bigger hospital that unfortunately is dominated by the large orthopedic group I mentioned earlier. None of the orthopedic surgeons from this group will even let these residents scrub their cases, let alone actually do anything.</p>
<p>This egotistical, bigoted stance infuriates me when I see how it can and should be. It is not 1990 when I did my residency and these residents deserve better. This program could be so much better than it is if orthopedics would participate in the training. I know certain parts of the country are better than others on this topic but central Indiana is often extremely slow to change on issues like this. The hospital is equally at fault here as well. It is happy to accept the money for having a podiatric residency program but could give a damn about the quality of education these residents receive. What hypocrisy this religious institution displays especially considering their motto: “The Spirit of Caring.” Where is the administration’s caring for the podiatric resident’s education? I am sure they “care” about the money the residency program generates. There is a lot of “caring” there.</p>
<p>Unfortunately, discrimination against podiatry still exists but I see less and less of it all the time. We must continue the fight and as Gandhi said, “first they ignore you, then they laugh at you, then they fight you, then you win.” I love many of Gandhi’s quotes and this one particularly applies. We are fighting the good fight and we are winning, albeit not as quickly as many of us would like. I have hope as I have glimpsed the harmony that can and does exist.</p>
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</div></div></div>Wed, 05 Nov 2014 13:29:16 +0000Patrick DeHeer DPM FACFAS4689 at http://www.podiatrytoday.comhttp://www.podiatrytoday.com/blogged/do-podiatrists-face-less-discrimination-orthopedic-surgeons-these-days#comments